Report highlights lapses at Brockton, Mass. VA Hospital

BROCKTON, Mass. (Tribune News Service) — Almost six months after inspectors found two nurses asleep on the job at the Brockton Veterans Administration Hospital, a special counsel issued a report condemning attitude of staff at the Brockton facility.

A nurse, who has since resigned from the hospital, reported to the Veterans Administration that she saw nurses failing to make rounds through the Community Living Center, a nursing home in the sprawling VA complex. Her report triggered an inspection in May 2018 by the a branch of the Veterans Administration called the Office of the Medical Inspector.

When inspectors visited the hospital, they confirmed the whistleblowing nurse's allegations that nurses often did not meet the Veterans Administration's expectations.

"Community Living Center nursing staff have repeatedly failed to meet agency standards of care," the report says. Though they found no evidence of veterans who had been harmed or neglected, inspectors wrote they were disturbed by the "blatant disregard" of the staff.

According to the report, at 2:40 a.m. on May 24, inspectors found a registered nurse and a certified nursing assistant asleep while on the clock—one was wrapped in a blanket, behind a locked door, the other sleeping on chairs behind a partition. Both told inspectors they were on break, but the hospital fired both as a result of the inspector's findings. Despite the sleeping staff, inspectors wrote that they did not find any evidence that patients had been neglected or harmed that day.

The whistleblower also alleged she was instructed to lie about how long a patient had been on the floor after a fall before staff found him. Inspectors were not able to verify that claim.

"Because a brave whistleblower came forward, VA investigators were able to substantiate that patients at the Brockton community living center were routinely receiving substandard care," Special Counsel Henry J. Kerner said in a written statement.

Hospital spokeswoman Pallas Wahl said the hospital appreciated the oversight from the Office of the Medical Inspector, and said the hospital conducted an internal investigation after the whistleblowing nurse made complaints to the hospital administration. Wahl said the hospital has implemented the corrective actions inspectors suggested, including random checks to make sure nurses are making their rounds, and firing the pair of sleeping nurses.

Earlier this year, the VA released ratings for its nursing homes to the public for the first time, following its 2016 release of hospital quality ratings. The Brockton nursing home, the same unit inspected by the VA, earned just one star out of a possible five for quality.

"We do not agree with the implication that Brockton offers low quality care," Wahl said. But she added that the hospital does take the rating system seriously.

On his way into an appointment in the hospital on Wednesday, retired Marine Alfred Needham defended the hospital staff who cared for him in the Community Living Center as he recovered from a surgery to remove a benign tumor in his brain.

"The doctors and the staff are great," he said. "The nurses and the doctors are very caring. They helped me out immensely." His complaints centered on the VA facilities: cold water in the showers, few activities to fill the day, and bad hospital food. "They've taken out a lot of things I guess for money reasons," Needham said.

But it did not surprise him that the VA inspectors found two nurses asleep on the job. "There's always that 10 percent, anywhere you go" he said.

Colleen Rapoza's Vietnam veteran father was checked in for a short stay at the Community Living Center in February. Rapoza said she was not immediately impressed with the care he received. She and her family weren't always around when her father was first hospitalized, and Rapoza felt her father was being neglected.

Once she and her siblings started showing up every day to advocate for his care, she noticed nursing staff gave him more attention. But Rapoza did not blame nurses, she said.

"The entire medical field is understaffed." She said she understood how a patient might slip through the cracks, "Unless you're there to say, "Hey!""

She's happy with the care her father received at the Brockton VA. "They ended up doing wonderful things for my father in the end," she said.

Like Needham, Rapoza wondered if the funding of the Veterans Administration affected the quality of care. "The people that work there are great. They do the best with what they're given."

She sometimes noticed nurses sitting around chatting, but never saw one sleeping.